‘Medicine copies aviation to stop errors, deaths’
What’s about this anti-error project?The project I am working on with my colleagues at the Byron Institute is looking at ways to prevent medical errors, and when they occur, to quickly correct them and also to give physicians and nurses and all frontline workers to learn ways to detect medical errors before they occur. When […]
What’s about this anti-error project?
The project I am working on with my colleagues at the Byron Institute is looking at ways to prevent medical errors, and when they occur, to quickly correct them and also to give physicians and nurses and all frontline workers to learn ways to detect medical errors before they occur. When they do occur and we don’t detect them, we can’t correct them.
We want to create awareness in the medical community that, ‘do you know what, we can prevent errors in medicine.’ We are trying to now benchmark medicine to high-reliability organisations. There are certain industries that have worked very hard to increase safety and quality. Immediately we must mention aviation. In asmuch as there is a crash, many people die, what we fail to realise is there are many departures every day, hundreds of thousands of airline departures around the world, and it is once in a blue moon we hear the crash.
One passenger in 10 million departures will die as a consequence of flying. Look at health, one in a thousand will die as a result of medical error. They are doing something right and medicine needs to copy from them. There is still another high-reliability group even better than aviation, and that group is the nuclear power system. Nuclear-powered stations record one death in 100 million as a consequence of residing in the vicinity of a nuclear-powered station.
What is it these people are doing that we can replicate in healthcare to improve quality? What we do in this training is to see if we can have zero event of harm. Now you say medicine is a human discipline and humans do err, compared to machine. The beauty of those systems is they are closed systems—not everybody walks into a nuclear power station or a cockpit. In medicine, it is an open system. Everybody can walk into a hospital, go anywhere. This creates events of error. People walk into a hospital and interrupt a process at a critical point because they do not know. You can’t walk into a cockpit and start talking to the pilot. Most times, phones will ring in the middle of a consultation, nurses will receive calls, patients will flow in and out, some patients will even stagger inadvertently into an operating room where operation is going on. That is not happening in aviation and nuclear power.
What we are looking to do is create high-reliability zones where the patient is at the centre of the activity of all healthcare practitioner. We look for effectiveness in the treatment we give, we make it patient centred—in other words, we respect the patient as a person.
People don’t realise the patient notice everything you do: the way you receive them, whether you are paying attention, whether they are the centre of your focus or if you just see them as a nuisance. That also affects the result. Most patients will not comply with treatment from a person whom they felt wasn’t even paying attention to them.
The US has one in a thousand deaths. We try to situate that in Nigeria and we hear figures like one in 500. Some [forums] where I have been present, people have said it is worse than that: it is one in 100. They are saying that for every 100 patients we admit, one will die. That is unacceptable.
Everything being equal, how can we make sure we achieve a better rate than one in 100? The next thing is that there is insufficient funding for health. In this same city of Abuja, the Abuja Declaration was signed: that 15% of gross domestic product of every signatory nation should be dedicated to health, and we know that the actual is 4.3%. Other nations that were signatories are approaching 10 to 11% of their GDP—Rwanda, Tanzania, Kenya.
It is argued that it is not a matter of 15% or 4% of GDP thrown into health but how the funding is managed. If the human factor, skill, knowledge gap is not addressed, where does that leave us?
The training of doctors in Nigeria reached a point where it became almost impossible to graduate any specialist. The reason being: in the past, when you graduate as a doctor, you did your internship; you started a residency programme to become a specialist. And because we recognise that Nigeria is not yet at par with other nations in the West, we sent our doctors in their third year of specialisation for one year abroad, either in the UK or the US—to make them specialists of world standard. That training stopped almost 20 years ago. What it implies is that the experience Nigerian specialists had was totally and completely Nigerian based. Those 20 years were also the years of SAP—Structural Adjustment Programme – which meant funding of health centres, universities, institutions dropped drastically. The point I’m making here is that knowledge and skill gap was crushed.
In an analogy with aviation industry, how much training of future pilots is done outside Nigeria?
Because of my study in this area of high reliability, I have had to be fully involved in the training in those organisations on which we are trying to benchmark health. For pilots, it is a continuous training programme abroad.
We have copied their checklist, their crew resource management. We are trying to do what they do to make sure that team is working together, and that can only come out of training. We have recognised that errors come out of medicine because of the hierarchical nature of medicine. The professor has spoken, everybody else zip, you can’t say anything. But we are changing that. We are saying ‘you should be able to stop the line, press the red button, we are about to commit an error that can result in death. Professor, sir, I have a concern.’ Any member of the team, including a nurse, can say, “professor, I think this dosage for this drug for this patient with this body weight is inappropriate.” And the professor should say, “are you sure, how do you know that?” “Oh, I just researched it online.” And the professor should be willing to listen.
But that would only work when every cadre of health workers has the optimal training they need—from the anaesthesist to the scrub nurse.
Absolutely, and to achieve that, you need to have a budget for training that is adequate. Including the cleaners and porters. Recently I had to advise a hospital to take all its porters back to training, at least to be able to read. You say, ‘oh, they are porters, they are just to lift the patient’ but they are part of the error chain. A porter who could not read was sent to pick a patient to the theatre and he went to the wrong room.
There are levels of checks to ensure the right patient gets to the operating table. The next person to see that patient is the theatre nurse, who receives the patient from the porter. The anaesthesist again is supposed to check the band (on the patient). This is why we are saying no patient should be admitted without a wrist band, showing their name, hospital number, address. In Nigeria it is not happening. And sometimes the beds have been swapped. A patient says, ‘my AC is not working, move me to another room.’ And nobody has told the system, ‘patient A is now in room 20.’ They go to room 20 without even seeing the patient’s name and pick him.
Patients usually don’t complain. That’s another place where we can check it, but patients are usually quiet. The surgeon has the last chance before taking his knife to ensure this is the right patient. Again, because the surgeon’s mind is to operate will assume this woman has brought the right patient.
We train on the Swiss cheese effect. There are many holes in health care. The more holes we have blocked, the fewer errors we have and we might achieve zero error.
Is the Nigerian medical scene ready for this?
Training has changed blood transfusion with the three-finger check: [that information on patient blood band, blood bag and paperwork tally]. If any of the three items does not agree, no blood transfusion. If they do this three-finger check, the error margin is one in 10 million. There are ways we can ensure errors do not occur.
In the past when a medical practitioner has made a mistake the tendency is to hide it, and the reason is it was a punitive atmosphere. They punished you for telling the truth: the system will query you, send you to disciplinary committee, most likely fire you. People were forced to hide mistakes. What we are now teaching is: let it be a non-punitive environment, no punishment for honest errors. Not negligence. Negligence, incompetence, those are not to be tolerated.
The thrust is to prevent. We don’t want errors to occur, but when they do occur, let the person admit there’s an error and let the system quickly jump in to reverse the error. That will not happen in an environment where staff feel they will be punishable, or seen as the snitch. The workplace has to be created such that it is free of fear, and fear is the main reason people do not admit to errors.
The reverse-trace method allows us to trace errors back. If we are lucky it didn’t occur, it is still an error that could have occurred, we should still treat it as if it occurred, and go back step by step to see where it is caused and fixe it. That is the only way healthcare can begin to approach the level of reliability of aviation and nuclear power.